Following successful establishment of Expanded Program on Immunization
(EPI) in the 1970's as vertical program, the burden of disease for many
of the vaccine preventable diseases was pushed to low levels. The
current round of health reforms in Tanzania calls for decentralization
and integration of vertical programs. This has the potential to assist
or erode generally good performance of EPI. Reforms on the programme
have been undertaken in Tanzania since 1996, and have included 1)
integration of the procurement, storage, and distribution of vaccine
and related equipment into the operations of a quasi-autonomous drug
procurement agency. 2) government financing of procurement of the oral
polio vaccine, cold chain kerosene, and 3) the integration of kerosene
and vaccine distribution, supervision and monitoring to district health
system. Our analysis shows that the integration of the procurement and
distribution of vaccines into the operations of the drug procurement
agency, and privatization of the distribution of the cold chain
kerosene initially stalled EPI reforms for several reasons and had an
adverse effect on EPI decentralization and coverage. The major cause of
the problems was opposition from the EPI providers at district level
who had to accept decreased income consequent to the reforms. We
conclude that greater involvement of all stakeholders in the planning
of the programme, would have presented an opportunity for forecasting
the opposition and developing mitigating strategies.
Advocates of health system reform are calling for, among other things, decentralized, autonomous managerial and financial control, use of contracting and incentives, and a greater reliance on market mechanisms in the delivery of health services. The family planning and sexual health (FP&SH) sector already has experience of these. In this paper, we set forth three typical means of service provision within the FP&SH sector since the mid-1900s: independent not-for-profit providers, vertical government programmes and social marketing programmes. In each case, we present the context within which the service delivery mechanism evolved, the management techniques that characterize it and the lessons learned in FP&SH that are applicable to the wider debate about improving health sector management. We conclude that the FP&SH sector can provide both positive and negative lessons in the areas of autonomous management, use of incentives to providers and acceptors, balancing of centralization against decentralization, and employing private sector marketing and distribution techniques for delivering health services. This experience has not been adequately acknowledged in the debates about how to improve the quality and quantity of health services for the poor in developing countries. Health sector reform advocates and FP&SH advocates should collaborate within countries and regions to apply these management lessons.
Background: Health account is one method to acquire information about financial situation in the district or the state. Based on the information, the analysis on the policy can be made, such as priority setting and equity. The information is also used for policy decision and financial planning. Complete health finance data can be acquired in condition when there is a district health account.\nObjective: To describe health financial before and after the decentralization was implemented (1998 to 2002) in Sinjai District.\nMethod: This research is a quasi experiment research with before and after design. Method of health account development, is adopted from National Health Account.\nResult: This research showed that there was an increase of health funding since 1998 to 2002 in Sinjai District obtained from the government. Before decentralization central government role in health finance was high (11,6% to 60%), but after decentralization, the role of central government decreased and district government role increased (24% to 83%). From finance intermediary site the role of hospital as finance intermediary increased since 1999 to 2002 (11% to 40%). District Health Official still! took prominent finance intermediary point in Sinjai District. From health provider site, health expenditure allocation at community health center showed a trend to decrease. Health care administration and investment function showed escalation trend. Public health action constantly decreased since 1998 to 20002.\nConclusions: Sinjai District Health Finance increased since 1998 to 2002. Due to the increase of hospital health financial allodation, hospital finance intermediary also increased. On the other hand, the financial allocation in public health programs decreased. This pattern of health finance should be reserved for a pro-poor resource allocation.\n\nKeywords: health finance, District Health Account
Innocent Semali, Don de Savigny, M Tanner, C. Akim
Following successful establishment of Expanded Program on Immunization (EPI) in the 1970's as vertical program, the burden of disease for many of the vaccine preventable diseases was pushed to low levels. The current round of health reforms in Tanzania calls for decentralization and integration of vertical programs. This has the potential to assist or erode generally good performance of EPI. Reforms on the programme have been undertaken in Tanzania since 1996, and have included 1) integration of the procurement, storage, and distribution of vaccine and related equipment into the operations of a quasi-autonomous drug procurement agency. 2) government financing of procurement of the oral polio vaccine, cold chain kerosene, and 3) the integration of kerosene and vaccine distribution, supervision and monitoring to district health system. Our analysis shows that the integration of the procurement and distribution of vaccines into the operations of the drug procurement agency, and privatization of the distribution of the cold chain kerosene initially stalled EPI reforms for several reasons and had an adverse effect on EPI decentralization and coverage. The major cause of the problems was opposition from the EPI providers at district level who had to accept decreased income consequent to the reforms. We conclude that greater involvement of all stakeholders in the planning of the programme, would have presented an opportunity for forecasting the opposition and developing mitigating strategies.
The current need and enthusiasm for health reforms open an important arena for deeper analysis of the policy process with a view to understanding the political determinants of reforms and strengthening implementation. The studies described in this thesis analyse positions of different actors in the reform process, their actions in support or opposition of the process, and their impact on the health sector reform process. Globally and especially in developing countries health sector reforms have been implemented over long periods. Although there have been improvements in health, the remaining burden of disease in many countries is still very high. Reasons for the high burden of disease have been classified into lack of resources and poor organizational and managerial capacity. Good stewardship was needed to facilitate improvement in the performance of health systems. Stakeholders’ alignment and support was one of the most important components of good stewardship. However, stakeholder analysis had not been a common undertaking in developing countries despite the reforms that were being implemented in most of them. It was the aim of this study to answer the question: What has been the role and importance of stakeholders in supporting or opposing the health sector reform process? The study was conducted in Tanzania as one of the poorest countries in Africa, using the decentralization of the Expanded Programme on Immunization (EPI) as a case reference. The study units were the Ministry of Health Headquarters, Medical Stores Department, Expanded Programme on Immunization, national archives, regions and districts. At district level the study units were District Council, Council Health Management Team, EPI managers at regional and district levels, ward and village authorities, health facility, facility providers and households. Qualitative and quantitative methods were used to collect data from January 2000 to June 2002. Relevant data collection instruments were prepared and pre-tested. The qualitative data collection methods included document review, \nin-depth interviews, key informants interviews and observations. Quantitative \nmethods involved retrieval of secondary data, health facility survey and \nhousehold surveys. Regular discussions with key informants and data \ncollectors were held to verify the findings. Qualitative data was analysed \nmanually. Quantitative data was captured and analysed using Epi Info version \n6.1 and STATA version 6.0. The study involved answering five main questions. The first question was: Do \nreforms learn from history? Analysis of the waves of health reforms prior to \nthe current reforms from 1926 was done to answer the question. The main \nstakeholders in the reforms were the political party in power, the government \nand donors who supported the reforms each time. Each wave of health sector \nreforms provided information on health provision, financing and resource \ngeneration. Due to the political contexts, information on failures of health \nfinancing did not provide lessons for succeeding reforms of the health sector. \nStakeholders’ political interests opposed lessons that did not match the \npolitical ideology at the time i.e. free public services versus privatization and \npaying for social services. Lessons from previous health reforms were \nselective, and did not consider health-financing needs among others. The \nongoing health reforms needed to use information from all functional aspects \nof the health system to provide lessons for improving the health system. The second question was: Who were the stakeholders in the current health \nreforms and what were their interests and reactions? The main stakeholders \nwere donors, and the government. The two had a very high support for the \nreforms evidenced by their participation in problem identification, justification, \nreform design, planning and implementation. The health sector reforms thus \nhad high political support at central level. In the implementation process, \nissues that triggered stakeholders’ reaction included sectoral versus local \ngovernment decentralization. Another issue was the donor modality in \nfinancing the health sector and need for adopting new financial management \nsystems. Among the donors there was hesitancy to join the common financing \nmodalities that included a Sector Wide Approach (SWAp) and Basket \n Funding. As a result, there was delay in the process in order to reach better \nconsensus. \nThe third question was: What was the impact of stakeholders in the process of \nreforming a vertical programme like EPI? Health Sector Reforms in EPI \nincluded integration of generic functions, for example, vaccine procurement to \nmedical stores department. Qualitative and quantitative data was collected \nand analysed from the Ministry of Health, EPI management unit. This again \nrevealed that EPI reforms were well supported by the government and donors \ncentrally. EPI managers at both district and regional levels opposed some of \nthe EPI reforms. They argued that coverage was falling due to the reforms. \nHowever, there was no concrete evidence relating reforms in the EPI \nprogramme and falling coverage. The primary aim of certain actors was to \nmake sure that they continued receiving extra income from EPI functions. One \nof the effects of stakeholders’ reaction was reversal of reforms (recentralization) \nand return to the status quo. The fourth question was: What was the immediate reaction of stakeholders to \ndecentralization at district level and how might it have affected performance of \nEPI functions and the challenges? The immediate reaction of stakeholders \nwas reduced cooperation between the Council Health Management Team \n(CHMT) and the District Council who were politically supreme in the district. \nWithin the Council Health Management Team there was inadequate \ncommunication, which led to poor teamwork. The result of this was reduced \nsupervisory visits to peripheral health facilities. The EPI coverage in the study \ndistrict was 52.8 per cent, which was well below the previous national average \n(80 per cent). A logistic regression model for EPI service quality variables on \nchildren between 12 months and 23 months who had completed vaccination \nwas applied. Certain EPI quality of service variables predicted significant \nchanges in the odds ratio for completing vaccination. It was then suggested \nthat strategies were needed to improve management skills among the CHMT \nand District Council members. Also there was a need of hastening the \nprocess of increasing remuneration and motivation of peripheral health \nworkers. The fifth and final question was: What was the interest of the stakeholders \nand prospects of increasing EPI coverage at district level? Decentralization \nand integration of EPI functions were among the reforms at district level. The \nanalysis revealed that active stakeholders at district level were the Ministry of \nHealth, CHMT, EPI managers at district and regional levels and facility \nproviders. The Ministry of Health opposed integration of EPI at district level by \nissuing the directive that DCCOs and MCHCOs (EPI manager at district level) \nshould resume their tasks. However, the CHMT had no option but to comply. \nThis action reversed some of the health reforms at district level. Analysis of \nthe importance the community attached to EPI, using willingness to pay for \nEPI cold chain kerosene, was done. The support was low (48.7 per cent). EPI \nservice quality variables were significantly negatively associated with odds \nratio for willingness to pay for EPI input. Simulation with Policy Maker \ncomputer software predicted that an increased number of stakeholders \nthrough community participation would significantly improve the current low \nlevel of EPI coverage. It was then proposed to do a similar analysis in other \nvertical programmes and implement on a trial basis the results of the \nsimulation. \nIn conclusion, stakeholders were found to be active and influential in the \nhealth sectors of developing countries like Tanzania but poorly considered in \nimplementation of reforms. Stakeholders are important since some strongly \nsupport while others oppose the reforms. The reaction of stakeholders is \nevident through deployment or non-deployment of information depending on \ninterest and context. This would result in poor management leading to \ninefficiency in resource use, which would then be followed by poor quality of \nservices, poor support by communities and consequently poor utilization of \nhealth services. It is suggested that stakeholder analysis be conducted in \nother vertical programmes in the process of integration. Promotion of \nstakeholder analysis and also Policy Maker as a tool to manage stakeholders \nwill facilitate the management of reforms in the health sector.
Introduction There is global consensus on speeding up action against HIV/AIDS to mitigate the impact of the epidemic as rapidly as possible. However, there are no common blueprints on how to organize and manage accelerated HIV/AIDS prevention, care and support programmes to be followed by countries. Countries have tried to develop their intervention measures on the basis of local realities and international experiences available to them. The Ethiopia HIV/AIDS programme implementation process involves a high degree of the learning-by-doing approach, which capitalizes on positive lessons learned further to speed up action against HIV/AIDS. This article is a modest contribution and an example of what can be done in Africa in response to the epidemic in terms of project preparation and implementation (Table 1). It is hoped that some of these experiences can provide useful lessons for the preparation and implementation of HIV/AIDS prevention and control programmes in other countries.Table 1: Landmarks in the history of HIV/AIDS interventions in Ethiopia. Brief history of HIV/AIDS in Ethiopia and rationale for intensified action AIDS is now the leading killer in sub-Saharan Africa. Globally, Ethiopia has the sixteenth highest prevalence of HIV/AIDS and the third largest number of people living with HIV/AIDS (PLWHA), after South Africa and India. The primary modes of transmission in Ethiopia are sexual contact (heterosexual) and perinatal/mother-to-child transmission. Although the magnitude of the problem has yet to be sufficiently assessed, harmful indigenous practices and unsafe needle injection may be considered to be mechanisms for the spread of the virus in view of the wide practice in Ethiopia. The first evidence of HIV in Ethiopia was noted in 1984, and the first two AIDS cases were reported in 1986. HIV prevalence remained low in the 1980s, but has increased rapidly since the early 1990s. HIV prevalence increased from 3.2% in 1993 to 7.3% in 2000 (Fig. 1) [1]. During the same period, increasing trends were noted among women attending antenatal clinics in sentinel surveillance sites with notable regional variations. Estimated adult HIV prevalence according to the Ministry of Health in November 2000 was 16.8, 13.4 and 5% for Addis Ababa (capital city), other urban areas and rural areas, respectively.Fig. 1.: Ethiopia – adult HIV/AIDS prevalence.Initial HIV/AIDS-related activities in Ethiopia A National Task Force for HIV/AIDS was established in 1985. Two medium-term HIV/AIDS prevention and control plans were designed and implemented between 1987 and 1996, with the emphasis on information, education and communication, condom promotion, surveillance, patient care and the expansion of HIV screening laboratories in different health institutions. However, the interventions were limited in scope and there was little involvement of communities, sector ministries, non-governmental organizations (NGOs) including religious organizations and private organizations. The extent of interventions did not correspond to the fast spreading nature of the infection. Factors leading to organizational changes in the management of HIV/AIDS programme Global evidence of the adverse effects of unchecked HIV/AIDS epidemics on the socioeconomic situation of countries and the international movement to scale up action against HIV/AIDS have in no small way influenced the Ethiopian government to take accelerated action against the HIV/AIDS epidemic. Also, the First International Conference on AIDS in Ethiopia held in Addis Ababa on 7–10 November 1999 provided an additional forum for generating the support and commitment of high government officials to enhance HIV/AIDS interventions in Ethiopia. The government of Ethiopia became conscious of: (i) the devastating effects of the increasing infection rate that had reached epidemic proportions; (ii) the devastating impact of HIV/AIDS with the huge number of deaths severely straining the traditional social coping mechanism (the EDIR, a social organization created by communities to support families during funerals); (iii) the weaknesses of the existing organizational set-up to handle the rapid progress of the infection; and (iv) the common understanding that if the epidemic is left unchecked, it will alter the trajectory of the country's development by retarding growth, weakening human capital, discouraging investment, exacerbating poverty and increasing inequality. Ethiopia, therefore, in August 1998 approved a comprehensive HIV/AIDS policy to provide guidance and direction to the preparation of a multi-sectoral and multi-partner HIV/AIDS prevention and control programme. A National HIV/AIDS Council composed of ministers, regional heads of state, civil society, religious leaders, NGOs and PLWHA was established under the chairmanship of the President of the Federal Democratic Republic of Ethiopia in April 2000. The National Council has appointed the National Advisory Board, which meets monthly to provide direction and guidance to the implementation of the multi-sectoral HIV/AIDS control and prevention programme through the National HIV/AIDS Secretariat and its Project Coordinating Unit (PCU). Regional and local coordinating bodies were also established to facilitate the implementation of HIV/AIDS interventions at the community level. Influence of global HIV/AIDS movements on HIV/AIDS programmes in Ethiopia Globally, HIV/AIDS is now treated as an economic crisis and not merely a health problem. Successful HIV/AIDS interventions under such circumstances require actions as broad as the epidemic itself and intense enough to respond effectively to the level reached by the epidemic. The resource needs of such massive interventions are too enormous to be sufficiently addressed by many developing countries. A number of international agencies have expressed readiness to increase their commitment substantially in the fight against HIV. In order to realize this commitment, an International Partnership Against HIV/AIDS in Africa was formed, and UNAIDS was established co-sponsored initially by UNICEF, UNFPA, UNDP, UNESCO, WHO and the World Bank. The number of co-sponsors has since increased. The co-sponsors and UNAIDS secretariat met in Annapolis, Maryland, USA, on 19–20 January 1999, and agreed to work together to slow the spread of HIV in Africa drastically, and enhance a sustainable political and social mobilization at an unprecedented scale in order to reduced HIV transmission and suffering and to mitigate the impact of HIV/AIDS. The World Bank, conscious of the crisis created by the epidemic and the consequences of inaction, and convinced that it could play a greater role in HIV/AIDS prevention and control, prepared a strategic document in May 1999 [2] entitled ‘Intensifying action against HIV/AIDS: responding to a development crisis'. The Bank's new strategic plan placed HIV/AIDS at the centre of its development agenda to combat the epidemic, in partnership with African governments and UNAIDS. To stimulate and support the implementation of the strategy, the World Bank took three major actions: (i) established a multi-sectoral AIDS Campaign Team for Africa (ACTAfrica); (ii) directed all bank projects to include an HIV/AIDS component; and (iii) made available an initial US$500 million fund to be drawn by African countries to scale-up their HIV/AIDS interventions. A second amount of US$500 million was recently approved by the board of the World Bank. The global mobilization efforts have to a great extent encouraged the government of Ethiopia to intensify the action against HIV/AIDS to reverse the tragic situation. Enabling environments (internal and external) created to scale-up HIV/AIDS interventions in Ethiopia The global movement to accelerate and expand action against HIV/AIDS has created a potential for the increased availability of essential resources to developing countries. In Ethiopia a number of international and bilateral donors (e.g. WHO, UNICEF, UNDP, UNFPA, UNAIDS, ILO, USAID, DFID, GZT, DANIDA, Irish Aid, Norway, the Netherlands, Italy, the World Bank) have either provided support or are finalizing their project support. The government of Ethiopia approved a multi-sectoral and comprehensive HIV/AIDS policy that created an enabling environment for a wide range of HIV/AIDS prevention and control activities. The establishment of the National HIV/AIDS Council, the Advisory Board, National and Regional HIV/AIDS Secretariats, and their decentralized bodies have established potentially appropriate organization and management structures to lead expanded and intensified HIV/AIDS interventions throughout the country (Fig. 2).Fig. 2.: Organizational structure for HIV/AIDS management programme. NGOs, Non-governmental organizations.The World Bank has made funds available to countries including Ethiopia to draw from its initial allocated fund for HIV/AIDS. The Ethiopia Multi-sectoral HIV/AIDS Project (EMSAP) finances a 3-year (2000–2003) government HIV/AIDS strategic plan that is estimated initially to cost US$63.4 million [3,4]. The World Bank has approved US$59.7 million to help pay for the project, of which more than US$28 million is earmarked to support civil societies and community-driven HIV/AIDS initiatives. The process undertaken during the preparation of the Ethiopia Multi-Sectoral HIV/AIDS Project After formulating the national HIV/AIDS policy and preparing the National HIV/AIDS Strategic Framework [5], the Government of the Federal Democratic Republic of Ethiopia requested the World Bank to support its efforts to accelerate and expand action against the epidemic of HIV/AIDS in the country. As the request was in line with the global commitment and strategic plan of the Bank, the Bank agreed to the Government's request as long as there were institutional arrangements in place, such as the formation of a National AIDS Council, the establishment of the National Secretariat and the appointment of a National Task Force to lead the process of project formulation and development. The National HIV/AIDS Council was inaugurated in April 2000, and the appointment of the head of the National Secretariat was announced in the same forum. The preparation of EMSAP started in July 2000. Again at the request of the Government of Ethiopia, a multi-donor HIV/AIDS identification and preparation mission was undertaken to facilitate the preparation of a fundable project for an HIV/AIDS prevention and control programme in Ethiopia. A preliminary consultation workshop was held early in July 2000 to assess the prevailing HIV/AIDS situation in the country, and suggest the scope and actions to be undertaken to address the epidemic. The participants included members of the newly formed National HIV/AIDS Council, representatives of major sector ministries, regional state representatives, NGOs, and members of the civil society (women, youth, PLWHA, religious organizations, academic institutions) and donors. On the basis of the briefing on the status of HIV/AIDS and discussions that followed, the meeting agreed on actions that needed to be taken to mitigate the effects of the epidemic rapidly. The meeting stressed the following points during its deliberations: That HIV/AIDS activities should be guided and directed by the highest authority in the Government and the National HIV/AIDS Secretariat should be directly under such an authority that commands respect for its directives by all concerned. HIV/AIDS activities should be community based and driven. A special emergency grant fund should be created to support civil society and community-based initiatives. The fund should flow directly to communities, circumventing the normally bureaucratic financial system of the Government. The establishment of such a financial system would help ensure a fast flow of funds to support communities to engage rapidly in scaled-up HIV/AIDS interventions. NGOs, private organizations, community-based organizations and PLWHA should be actively involved and supported to expand their HIV/AIDS interventions by directly providing grant funding to support their activities. The project should be designed in a way that provides flexibility. The participants of the meeting outlined the objectives, components and logical framework for EMSAP. On the basis of the strategic plan and the logical framework, the National AIDS Secretariat Task Force, with technical support from World Bank staff and other donors, developed a draft multi-Sectoral HIV/AIDS Programme. The main objective of EMSAP is to help reduce the spread of the HIV/AIDS epidemic, alleviate its impact, and increase access to treatment, care and support for those infected and affected by HIV/AIDS. The components of the project were identified as including: (i) capacity building of public and private institutions; (ii) the Government multi-sectoral (iii) the response of communities, NGOs and the private sector to mitigate the and (iv) project and A draft project document was prepared and to a second The draft document was also for to of the during the initial meeting and an international mission composed of UNAIDS and bilateral institutions. The draft document was on the basis of the and provided by and a document was which the Government for funding to donors. Brief of components and activities The project components the scope of activities that have to meeting the agreed The country has a limited public capacity to the newly HIV/AIDS programme. It was to the institutional capacity of Government civil society and the private sector at and to accelerate the implementation of the HIV/AIDS programme. in this include the of human and other to the national and regional and and HIV/AIDS bodies in the were on EMSAP and were to the Project and other and the multi-sectoral implementation response of government agencies The of this is to support the multi-sectoral response of government organizations to scale up their interventions in the fight against the expansion of HIV/AIDS. The initial interventions prevention condom and and and care and support for those infected and affected of financial and support to PLWHA and in this government organizations at the level have established HIV/AIDS and their work plans and for and by the National Advisory the work plans and were approved and funds have to of (Table approved and for projects by non-governmental organizations, private organizations and people living with HIV/AIDS by the National HIV/AIDS The Ministry of has held and and HIV/AIDS for and and is the formation and of The Ministry of has up condom availability and the and of The authority has not the of HIV/AIDS interventions as and condom infection and as of the with but also is in the process of HIV/AIDS interventions among its and work regional sector have developed and their work plans and to the regional HIV/AIDS fund The emergency HIV/AIDS fund is an of EMSAP. A number of NGOs and community-based organizations in the country are to potential that could be by providing additional and including The is designed to support NGOs, the private religious organizations and community-based organizations to scale up their HIV/AIDS prevention and control activities in order to reduce the of the epidemic as fast as possible. The has two for and and the other for NGOs, private organizations, PLWHA and civil societies for all two with and NGOs religious and private organizations have from the of the fund (Table programmes and care and support to those infected and affected has increased in scale and scope in of the and communities supported by of funds by the Project Coordinating Unit to ministries, regional and HIV/AIDS Although there are in the country, International support for community-based programmes will be in for the There have to increase the number of support. The is not the of funds but the capacity to provide the support to The process of implementation also involves that require of the experiences the of an is to what has and what needs to be or The process involves a high degree of learning-by-doing a of experiences Project and management The main of this is to help develop a and management system that is of coordinating and the the National Secretariat is the management and is to a under the direction of the National HIV/AIDS Secretariat The is with structures that include programme and and The of funds to International Government of of NGOs, non-governmental National Project Coordinating people living with Regional The has established with the essential and The provides support to the establishment of the regional The has more than for funding at a national and has the of some funds to the appropriate A and has established and a and has appointed in an to a and system for HIV/AIDS in the country. process and impact have identified to help the and of the an HIV/AIDS system has developed with the of The Ethiopian and with support from the is actively involved in HIV/AIDS the support of USAID, Health International is a on HIV/AIDS. of these are to to and the effects of the interventions. of the Ethiopian project EMSAP is by communities, NGOs and donors. the US$63.4 the is US$59.7 million The is to be by donors, NGOs and The financial management system two of the funds is provided through the government fund flow and the other is directly to that have established and financial control the of the preparation of many expressed a to support the project, but the created an that in a After the of in the a number of donors have to support the Government's HIV/AIDS programme. became on January this the World Bank is the major to the The major and experiences in the implementation of the project National and regional and have established and The and have formed in the first of and were appointed and are in and coordinating community-based activities. have funds from the centre and have started up HIV/AIDS interventions. activities have is as by the increase in the number of HIV/AIDS is with by private and public in a of in the for HIV/AIDS is through the UNAIDS In briefing are by the to on the status of implementation of the The financial and system and organization and have prepared to the management of the project at and other have provided to the and the regional to facilitate and activities. have placed for the of and to and the of by health institutions. for have prepared and In view of the by the of the epidemic, the management of the national and regional had to be rapidly and in a There was little for the and to and the implementation process of the project In the project has a a number of and which made In view of these the progress in implementation is not as fast as for an emergency The project is implemented by many and decentralized and were prepared and to coordinating and bodies to the implementation of the project the have useful in the implementation However, there is a to ensure to facilitate the of the to different The project by massive involvement of NGOs, the private sector and community-based organizations to scale up HIV/AIDS prevention and control interventions to mitigate the impact of the epidemic rapidly. This epidemic a coordinating mechanism at all as the government would to facilitate the of these in the and management capacity of the and regional have the of all those to be actively The of government is an of EMSAP. Although it is to that some sector have expanded their HIV/AIDS a number of require and support to increase the scope of their HIV/AIDS interventions. The development of the and system was special from the of the composed of national and international organizations in and was established to and provide for and development. A national and was and in and held in South Africa. action is needed to the and system a in the of an appropriate and system will the process of project actions are taken by all to enhance the establishment of a and learned The Ethiopia HIV/AIDS project was prepared a fast project preparation a fast preparation process was by the to resources for an emergency situation that had started economic and a on the existing social coping The of the project has not increased but has also the establishment of management structures essential for intervention international partnership was in and generating government to take action against HIV/AIDS. The Government of Ethiopia established a comprehensive HIV/AIDS a HIV/AIDS strategic and a multi-sectoral HIV/AIDS National Council, under the of the President of the Federal Democratic Republic of Ethiopia. In the government established a National HIV/AIDS Secretariat under the a under the National and a policy that the of all of which are essential for up HIV/AIDS interventions in the country. The government has that of activities in limited areas are to slow the rapidly increasing epidemic, and has up regional and that are now leading a against HIV/AIDS It is that in the epidemic an expansion of community-based interventions. The Government of Ethiopia has taken unprecedented measures to interventions at a community level by a to funds to flow directly to communities, and public funds available to support NGOs and private organizations. This action has made the rapid of to communities to help the rapid implementation of community-based which would have slow if the flow of funds had followed government As a of such a rapid progress has noted in some of the communities as by the increase in activities and support to those affected and infected the to all the during the first was The to the number of to has created a forum for what a learning-by-doing an to assess the in the and to the and of the intervention measures during the first learned during the first of implementation were to some of the in the of The level of and capacity of communities is in terms of their to The that communities are provided with and is not should be supported by community-based NGOs or other development to in the The the government has an implementation in has encouraged many donors to in HIV/AIDS interventions in the country. than donors are now a new commitment to provide additional technical and financial support. EMSAP is of the first two HIV/AIDS programme projects by the World Bank in sub-Saharan Africa. The of project preparation and of implementation have for many other HIV/AIDS projects in with of the scope and of the epidemic, and the readiness of many of the to fast action at the project level is and However, rapid project preparation and implementation and that to be addressed as early as possible. EMSAP the of the of the implementation process in order to and early measures to the project to its the adverse consequences of and conscious of the limited capacity of the existing the World Bank has taken special measures to support the national and regional and to accelerate the implementation of EMSAP. In to the support provided by the and the at the country a bank was to support the and the regional This has substantially to project implementation at all The National Secretariat and have with regional to assess progress and on actions to be taken during the following such have and the discussions and taken in these have created common understanding on project implementation and common to during The and the taken to an HIV/AIDS programme in Ethiopia can provide and for other developing countries on this public health A of the major the actions taken and are in The fast preparation process undertaken by this project in Ethiopia was in funds available to scale up intervention activities by communities, NGOs, private organizations and the public sector rapidly. The project a learning-by-doing than to programme in during which would have by of major action taken and the process project funds were directly to NGOs, community-based organizations, and communities to scale up rapid HIV/AIDS interventions at the local the are the of the project and the of of the the during the first are not the HIV/AIDS project in Ethiopia, a number of national and international organizations have now developed a partnership with the government by providing financial and support to the project to be in Ethiopia, trends have in and the expansion of care and support at the community level. A number of World Bank staff and international organizations have to the preparation and implementation of the project, and it is to all and organizations. The to the special contribution of the following in the and implementation of and The would also to their of the and support by the national and regional the Project and the international and bilateral organizations. the special support and to the by World Bank President for and the have support and guidance to the preparation and implementation of the
The Province of the Punjab underwent a number of attempts to decentralize the health sector in the 1990s. Among the most important were the decentralization of financial management within the district, the Sheikhupura PHC Pilot Project, the establishment of the District Health Authorities and District Health Management Teams, the creation of semi-autonomous hospitals and the programme of District Health Government (DHG). These usually received donor support and promotion, and emerged from within the provincial Department of Health, and more specifically the Secretariat and the internationally supported Second Family Health Project (FH2). Of particular significance was the DHG change, which involved a decentralization to the district, the appointment of powerful Chief Executives, the formation of District Management Committees and purchaser-provider separation. The paper reviews these proposals, focusing on the need to build on experiences and learning lessons from pilot projects, reform continuity, developing consultation and involvement and policy analysis. The latter indicates the importance of developing more in-depth policy analysis around the role of the central organization, the form of decentralization and the purchaser-provider separation. The paper concludes by underlining the need to ensure that political strategy and in-depth policy are appropriately coordinated in the policy process.
Introduction In the past 2 years, political commitment to respond to the HIV/AIDS pandemic has increased sub-stantially. The United Nations General Assembly Special Session on AIDS in 2001 and the recent creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria are two indicators of this commitment at the global level. At the regional level, HIV/AIDS has been an issue on the agenda of the Inter-American Development Bank, the Asian Development Bank, and the Organization of African Unity, to name but a few institutions. At the national level, low-income and middle-income countries, home to over 95% of people living with HIV/AIDS, have made important progress in HIV/AIDS planning and program development [1,2]. In this policy environment, the importance of information on resources for HIV/AIDS prevention and care has increased. More and more, policy-makers are looking for data on the level and flow of current allocations to HIV/AIDS. They want to know where money for HIV/AIDS prevention and care is coming from, the services and commodities that are purchased with these funds, and the population coverage of implemented interventions. At the same time, to identify gaps between what is and what should be and to plan strategically, policy-makers are seeking information on the scale of resources required to prevent the further spread of HIV and to provide adequate care for those people living with HIV/AIDS. Because the epidemic is so concentrated in low-income and middle-income countries, estimating HIV/AIDS resource allocations and requirements in these countries is key to responding effectively to HIV/AIDS world-wide. It is also in these countries that this task is most complicated. Program data, ideally produced by national health information systems, are required to monitor resource flows. In many of these countries, however, such systems are weak or nonfunctioning. Similarly, to derive estimates on resource needs, one requires a range of demographic, economic, and health data that are scarce or nonexistent in many developing countries. Notwithstanding these obstacles, significant progress was made during the past year in both monitoring the level and flow of current allocations to HIV/AIDS and estimating HIV/AIDS resource requirements in developing countries. The present article reviews the latest data and examines their policy implications. It identifies the gaps and limitations of current research. The article also discusses future directions to strengthen the quality of data on resources for HIV/AIDS prevention and care. Resources allocated to HIV/AIDS Few countries, whether low, middle or high income, regularly monitor resource flows to the HIV prevention activities conducted by government and nongovernmental institutions within their territory. To date, no country has developed a system that regularly tracks expenditures on HIV/AIDS care. The most well-established data collection activities documenting resource allocations to HIV/AIDS in developing countries are international initiatives. Each year, donors report their official development assistance (ODA) to HIV/AIDS and other sexually transmitted infections (STI) to the OECD Development Assistance Committee (DAC) [3]. Similarly, the Netherlands Interdisciplinary Demographic Institute surveys donors (annually) and developing countries (biannually) for UNFPA and UNAIDS on their HIV/AIDS/STI expenditures as part of their Resource Flows Project. The most detailed information on resource allocations to HIV/AIDS in developing countries comes from indepth country studies conducted on an ad hoc basis. Most recently, the Regional AIDS Initiative for Latin America and the Caribbean (SIDALAC) and the Partnerships for Health Reform have investigated HIV/AIDS financing in several countries using the National Health Accounts (NHA) framework [4]. The present section discusses the latest data from these sources. Table 1 presents the HIV/AIDS/STI ODA data reported to the Resource Flows Project between 1998 and 2000, with data reported to the OECD DAC imputed when no data was reported to the Resource Flows Project. Donor countries disbursed a total of US$ 454 million in 2000. According to reports to the OECD DAC, this represents 87% of the US$ 521 million that were committed or allocated to HIV/AIDS/STI projects during 2000. Total disbursements for 2000 represent a significant increase from the US$ 294 million and US$ 279 million disbursed by donors in 1998 and 1999, respectively.Table 1: HIV/AIDS/sexually transmitted infections official development assistance disbursements, 1998–2000 (US$ million)As in previous years, the United States was by far the largest donor of HIV/AIDS/STI ODA in 2000. However, when this ODA is broken down as a proportion of gross national income for each country, Luxembourg contributed the largest proportion of its gross national income (Fig. 1).Fig. 1.: HIV/AIDS/sexually transmitted infections (STI) official development assistance (ODA), 2000. Total amount obligated in US$ million and obligations per US$ million gross national income (GNI).What is revealed by these data and past surveys on HIV/AIDS/STI ODA [5–7] is that surveys provide reasonable information on these expenditures, albeit varying in comprehensiveness and accuracy. Past global surveys have also illustrated that questionnaires can provide relatively good data on HIV/AIDS resource allocations that flow into developing countries from the United Nations system and nongovernmental institutions in high-income nations. Although as HIV/AIDS is increasingly integrated into projects addressing broader health or development issues, HIV/AIDS expenditures are becoming more difficult to track even among these international institutions. However, questionnaires sent to national HIV/AIDS coordinating institutions to collect data on domestic resource allocations to HIV/AIDS are much less efficient tolls for gathering quality data. In part, this is because regularly updated information systems do not exist and it is difficult for national HIV/AIDS coordinating bodies to gather expenditure data from the many ministries and organizations implementing HIV/AIDS interventions in a country. In addition, for large portions of HIV/AIDS expenditure, data must be estimated with special studies. To estimate domestic expenditure on HIV/AIDS care, for example, studies costing selected services must be undertaken. Likewise, to capture how much individuals themselves spend on HIV/AIDS services (out-of-pocket spending), which in many countries constitutes the majority of overall AIDS spending, requires household or clinic-based studies of people living with HIV/AIDS. It is these information gaps that in-depth country studies using the NHA framework aim to fill. These studies attempt to account for all expenditures by looking not only at public sector financing, but also at spending within the private sector, including spending by individuals. They collect the data that are available and conduct special studies, such as limited household surveys, as necessary. Most of the studies on HIV/AIDS resource allocations using the NHA framework have been carried out in Latin America and the Caribbean (LAC) [8]. Referred to as National HIV/AIDS Accounts, they were first carried out in Brazil, Guatemala, Mexico and Uruguay in 1997/1998 [9–12], with substantial scaling-up of efforts occurring in the past year. SIDALAC recently completed studies in 12 countries (Argentina, Bolivia, Brazil, Chile, El Salvador, Guatemala, Mexico, Nicaragua, Panama, Paraguay, Peru, and Uruguay) and studies in three additional countries are underway (Costa Rica, the Dominican Republic, and Honduras)[13]. Total HIV/AIDS spending in the 12 countries in Latin America studied (representing 75% of the population of the region) [14] in 2000 was estimated at US$ 1.04 billion. This represents an average of US$ 2.70 per capita for the 12 countries, with individual country per-capita expenditure ranging from US$ 0.30 and US$ 0.60 in Bolivia and El Salvador to US$ 5.60 and US$ 4.90 in Uruguay and Argentina (Table 2). In terms of average expenditure per person living with HIV/AIDS (PLWHA) in the 12 countries, this translates into a little over US$ 1000 regionally, with over US$ 3000 spent per PLWHA in Uruguay and only US$ 175 per PLWHA spent in Guatemala.Table 2: HIV/AIDS expenditure in 12 countries of Latin America and the Caribbean, 2000.Overall, US$ 753 million (73%) of HIV/AIDS resources in the 12 countries were spent on care, with only US$ 283 million (27%) spent on prevention. This trend was true across countries with the exception of Bolivia and Nicaragua, countries with relatively lower prevalence rates, where only 34 and 36% of HIV/AIDS resources, respectively, were spent on care. Almost 72% of the resources spent on HIV/AIDS care in the 12 countries were spent on drugs, with the vast majority (almost 90% of drug expenditure) spent on antiretroviral drugs (ARV). Of course, social pressure for access to ARV in the region is high, and three of the 12 countries (Argentina, Brazil, and Uruguay) provide universal access to these drugs. However, this estimate does appear to be extremely high and may represent a bias since drug expenditures are easier to monitor than other components, especially when procurement of ARV is centralized through national HIV/AIDS programs, such as is the case in Brazil. With 60% of prevention expenditure on condoms and 14% on mass media campaigns, most of the prevention expenditure in the 12 countries was spent on interventions targeting the general population. This is notable in countries where HIV prevalence is still extremely low in the general population and the epidemic is concentrated among specific population groups [1]. In Mexico, Nicaragua and most of the Andean region, sex between men is the most prominent route of HIV transmission. Similarly, in Argentina, Chile, and Uruguay, injecting drug use is the main route of transmission. Given the epidemiology of the epidemic in the region, one would therefore expect that significant proportions of HIV prevention expenditures would be allocated to interventions targeting these population groups that are key to the expansion of the epidemic. However, only limited funds in the region (7% of prevention expenditure) were reported as allocated to such interventions. The major sources of HIV/AIDS funds also varied across countries. In Argentina, Brazil, Chile, El Salvador, Guatemala, Mexico, and Panama, the government health sector was the primary source of resources allocated to HIV/AIDS. In Paraguay, Peru, and Uruguay, private funds from enterprises, nongovernmental organizations and households were the primary sources of resources allocated to HIV/AIDS, while international sources provided most of the funding in Bolivia and Nicaragua. Even though studies using the NHA framework provide the most detailed estimates on resource flows in countries, they remain estimates that vary in completeness and accuracy. Although the studies attempted to account for all expenditures, the quality of the estimates depended on the availabilityand quality of financial and accounting data within relevant government and non-governmental institutions, and on the capacity of personnel within these organizations to formulate estimates where data were not available. It is probable, as mentioned earlier, that certain categories of expenditures, including spending on information, education and communication interventions, were underestimated because they were more difficult to track than expenditure on commodities such as drugs and condoms. It is also probable that expenditure by nongovernmental organizations, especially those that were community based, were under-reported since donated goods and services were not quantified adequately. Likewise, it is probable that in decentralized governments, with weak financial tracking at lower administrative levels, funds were missed or, alternatively, double counting occurred with expenditures being reported at higher and lower administrative levels. To estimate the expenditure on HIV/AIDS prevention and care for all countries in LAC, a regression was run to extrapolate the estimates for these 12 countries to the region. [A regression was run for these 12 countries with SIDALAC country totals as the dependent variable and the values from the care imputing exercise (described later) as the independnt variable.] The result is an estimate of US$ 1.4 billion for all countries in LAC. The only country outside of LAC where the NHA framework has also been used to estimate expenditures on HIV/AIDS is Rwanda. A study conducted for 1998 concluded that a total of US$ 10 million or US$ 1.27 per capita were spent on HIV/AIDS during that year [15]. This represents a total of US$ 25 per person living with HIV/AIDS, compared with the average of US$ 1000 per PLWHA in the 12 countries in Latin America already discussed. While spending in Latin America is large compared with spending in Rwanda (and presumably other countries in sub-Saharan Africa), even this expenditure is very small compared with expenditure by high-income countries such as the United States. The Federal Government spent US$ 10.8 billion on HIV/AIDS in the year 2000 [16]. If this amount is raised by the same proportion as that which prevails between public and total spending on health in the United States, then total HIV/AIDS spending can be estimated just below US$ 25 billion in 2000 [17,18]. This amount translates into nearly US$ 90 per capita, or just over US$ 30 000 per PLWHA. A check on the credibility of this seemingly high level of spending is provided by an analysis of spending on Medicaid-covered AIDS patients, which projected that expenditure would average almost US$ 36 000 per patient [19]. Resource needs for HIV/AIDS Similar progress was made in the area of estimating resource needs for HIV/AIDS over the past year. Two major studies of resource requirements estimates were published. The first, undertaken for the Commission on Macroeconomics and Health (CMH), estimated resources needed to scale-up a package of core interventions to address HIV/AIDS and other priority illnesses in 83 low-income and middle-income countries (including all of sub-Saharan Africa) by the years 2007 and 2015 [20,21]. The second, carried out in preparation for the UN General Assembly Special Session (UNGASS), estimated the cost of HIV/AIDS prevention and care needs in 135 low-income and middle-income countries in 2005 [22]. These two studies built on prior work on estimating resource needs for HIV/AIDS and used similar methodologies [23,24]. The methodologies used have been detailed previously [20–22]. Both studies included a selection of interventions that were costed based on published and unpublished project assessments (Table 3). Estimates were then made intervention-by-intervention and country-by-country using demographic, economic and epidemiological data to adjust the estimates to different country contexts. The main difference in methodology between the two studies was the inclusion in the CMH study of the costs for infrastructure strengthening necessary for scaling-up. In addition, there were differences in assumptions, with the most important being differences in target population coverage rates for the different interventions.Table 3: HIV/AIDS prevention and care interventions.The UNGASS study called for the annual spending of US$ 9.2 billion on HIV/AIDS prevention and care in low-income and middle-income countries by the year 2005, with up to US$ 6 billion coming from international sources. The CMH study concluded that, depending on coverage assumptions and price estimates, between US$ 13.6 billion and US$ 15.4 billion should be spent on HIV/AIDS prevention and care annually (including necessary infrastructure strengthening) in selected low-income and middle-income countries by the year 2007 in addition to what is already being spent, and that this should increase to between US$ 20.6 billion and US$ 24.9 billion by 2015. The ranges of the results within and across studies underline the fact that these are estimates with limitations. They underscore the data gap in low-income and middle-income countries and the many assumptions required while building each model to derive parameter estimates for which no data exist. As discussed further later, they should therefore be interpreted with caution and be seen as works in process that can be refined as new information becomes available on cost data, current intervention coverage estimates, and country capacity to expand services. Nonetheless, sensitivity analysis conducted usingthe UNGASS model confirms that study results provide a consistent estimate of the scale of resources needed. A probabilistic analysis that varied assumptions on intervention coverage, costs and country capacity to expand services produced a range of results that were comparable with the ranges reported in the CMH study. So, in short, the UNGASS and CMH estimates provide policy-makers with consistent information on the scale of the resources needed. But it would be inappropriate to use them to guide resource allocations among interventions at the national level. Although these two studies did differentiate across countries whenever possible, data limitations did not allow them to pay significant attention to individual country characteristics and the way in which those may affect overall costs. To improve the estimates so as to have them serve as tools for country strategic planning, both study teams recognized that additional country-level work would be necessary. This process has begun with individual country validations of the UNGASS estimates for the LAC region. The 10 countries to participate in a first phase of this effort were Brazil, Chile, the dominican Republic, Ecuador, El Salvador, Guatemala, Honduras, Jamaica, Mexico, and Trinidad and Tobago [25]. These countries increased the estimated resource requirement for HIV prevention by 15% and the estimated care requirements by 27%. The main differences in prevention estimates are accounted for by an increase in estimated resource needs for the social marketing of condoms and prevention of mother-to-child transmission, while the main differences in care estimates were due to important differences in the expected costs for highly antiretroviral Total expected resource needs for highly antiretroviral increased by compared with UNGASS To estimate the HIV/AIDS prevention and care needs for all countries in LAC, the estimates for these 10 countries were to the region using were run for the prevention and care estimates Because a was between the care data estimated by the countries and those estimated for used to the The used of to values for the countries that have not their The prevention exercise was similar in addition, it used the results of the care as an variable that was imputed with the regression than with the The UNGASS model called for US$ with US$ million for prevention and US$ million for care and prevention were refined the of the model estimates the estimate for Latin America and the Caribbean from US$ increased this by US$ million to almost US$ with US$ million for prevention and US$ million for care and the between the UNGASS estimates and those of the 10 is these estimates provide further for the overall of the To plan and to the policy-makers data on resources for HIV/AIDS prevention and care. a of public and private spending on the are to track and the of their to HIV/AIDS. estimate of the of resource needs to address the epidemic they are to plan and resources for the data that are available the for additional resources and for in the of those resources available. But to date, few policy-makers in low-income and middle-income countries countries that this information most have these data for their countries. are available on the annual official development assistance allocations to HIV/AIDS by high-income countries with limitations. These data that there was a significant increase in the flow of HIV/AIDS funding from high-income countries to developing countries in 2000, US$ represents only a of the estimated US$ billion in international resources required annually to respond to the epidemic in these countries. Similarly, in-depth country studies of which have been carried out in the vast in spending on people living with HIV/AIDS that exist These studies that an average of US$ 1000 per person living with HIV/AIDS was spent in Latin countries in 2000. This is more than estimates for sub-Saharan of people with HIV/AIDS of less than US$ and far less than estimates for the United States at over US$ 30 the results of the UNGASS model for LAC (almost US$ billion for the year with those of the National HIV/AIDS Accounts studies to the region (US$ 1.4 billion for further of the important policy that are raised by these of data. The higher estimates of current expenditure are due in part to the fact that the two estimates do not the resources with of interventions. The two also different assumptions on costs of and estimates of current intervention In addition, they are also based on different of countries and there are therefore different of in these estimates to the region. However, the difference in the assumptions made in the UNGASS model that the procurement of commodities such as and HIV is and that there is and in the of HIV interventions. The fact that estimates of current expenditure are higher than those for future resource needs in part the that result from that countries in the region to pay less for condoms and To strengthen the quality of HIV/AIDS financing data in developing countries, necessary the of studies to track National HIV/AIDS SIDALAC has that the process is The studies conducted in the region with the National Health Accounts by the Health Organization and the OECD have cost between US$ 25 000 and US$ 000 per year per country depending on country and This that in financial resources not be a to the of a system for monitoring HIV/AIDS resource flows. At the same time, estimates of country-level resource needs should be for all low-income and middle-income countries. are for the of the LAC region. Similar should be undertaken in sub-Saharan and one important HIV/AIDS prevention and care resources in developing countries is still estimates of resource needs should a not only resource needs, but also the provided by the resources on the expected from new would provide data to on the of resources within and across countries and The are to and of UNAIDS for the use of the HIV/AIDS/STI data reported to the Resource Flows Project. They the of the SIDALAC country from Argentina, Bolivia, Brazil, Chile, El Salvador, Guatemala, Mexico, Nicaragua, Panama, Paraguay, Peru, and Uruguay the data on the National HIV/AIDS They also of SIDALAC for assistance with the of the National HIV/AIDS Accounts data.
This paper addresses the decentralization of health services financed by the Unified Health System (SUS) in the city of Natal initiated in the mid 90s. This decentralization primarily involved the transference of health services financed by SUS, which had previously been developed by the state of Rio Grande do Norte, to the city government of Natal. Based on the data gathered mainly from SUS¿ Ambulatory Information System (SIS/SUS), the authors attempted to verify to what extent this decentralization of health services provided by SUS in the city of Natal had improved public access to health services or, on the contrary, had resulted in a privatization process, implying more difficult access to those services.
In international development, paradigms shift about once every 10 years. An important shift that is now taking place is from economic development to poverty reduction. The link between health and poverty has been recognized for a long time. The traditional way of looking at this is in terms of ‘wealthier means healthier’ ( Figure 1). While nobody disputes this link, the poverty reduction focus raises the question whether investment in health is important for poverty reduction. Quantitative evidence to answer this question is now emerging and producing astonishing findings. Health and income (a) the traditional view and (b) a new paradigm. In an analysis of geography, health and other factors in relation to poverty, Gallup et al. (1998) found one of the strongest correlations between poverty and malaria. In a longitudinal analysis of health, health policy and economic performance, Jamison et al. (1998) detected important time-frame relations between investments in health, the nature of these investments and economic performance. Bloom et al. (1998) found evidence that a change between dependent and the productive part of a population, i.e. reduction in fertility and increased child survival, can lead to a spurt in economic development. This demographic gift may be one of the reasons for the economic miracle in Asia. This effect is temporary and will turn negative when the cohorts grow old. At the microeconomic level there is also strong evidence for a link. For example, the programme fighting river blindness has given a 20% return on investment ( World Bank 1993). Moreover, families with river blindness spend twice as much on health as others, and their children are twice as likely to drop out of school, girls more often than boys. In a related chronic disease, lymphatic filariasis, patients produced 30% less material per hour than healthy cotton weaver coworkers ( TDR 1996a). Thus diseases and their underlying causes can affect the economies of families in a number of ways: Reduced productivity, impediment of education or retained high dependency ratios. The emerging conclusion is that the right investment in health is at least as important as education. While further quantitative research is needed to substantiate findings, leading decision-makers are are already convinced, as illustrated by the G8 resolutions at Cologne relating to debt relief for for highly indebted poor countries (HIPC). As the communique said, ‘The central objective of this initiative is to provide a greater focus on poverty reduction by releasing resources for investment in health, education and social needs’. The resources that could be available through the new debt relief initiative if not drained away in other directions are significant. According to estimates provided by Jeffrey Sachs (1999), the amounts are about 5 billion dollars annually for over 40 countries with a population of about 750 million. Thus we are considering about $7 per capita or $120 million per country. If health were allocated half of this, health spending could amount to $60 million per country. This has come at just the right time to accelerate our development of concepts and policies. In May a meeting between WHO and international development agencies dealt with the role of specific strategies in health to achieve poverty reduction ( WHO 1999a). In education the simple notion is that poor people are illiterate, so to secure basic schooling for the poor is paramount, and indeed much evidence supports that view. Similarly, the basic assumption in health is that the first priority in is to fight diseases from which the poor suffer most, i.e. their excess burden. Further analyses of what these conditions are, their quantitative relation to poverty country by country and relative importance as targets for investment to reduce poverty have been initiated. This has now become a priority for WHO (1999b). The major conditions linked to excess burden among the poor and their global importance in terms of mortality are set out in Table 1. According to ongoing work by Gakidou and Jamison (personal communication), they all show a strong excess in poor populations. Tuberculosis is 10 times more prevalent in people earning < $1 a day; maternal mortality about eight times, and childhood mortality (< 5 years) four to five times more common in children of poor families. One effect of this poverty reduction perspective is prioritizing and focusing. Thus we are faced with a limited set of predominantly infectious diseases. The question is, then, how to address them most effectively. What are the relative merits of the available tools in addressing disease burden? How cost-effective are they and what is their potential for reaching the populations in need? Clearly we need modules of different sets of interventions and need to look for synergies. From an immunization perspective we believe that with the pneumococcal vaccine soon becoming available, about 3.5 million deaths can potentially be prevented by immunization ( Table 2). Three and a half of 12.7 million (and let us add 2.3 million equivalents for family planning) would suggest that immunization could justify use of more than 20% of the resources on this basis alone, without taking into account cost effectiveness or capacity to reach the poor. In both these parameters immunization would, of course, score very high ( Miller & Hinman 1999). Based on the HIPC calculations with about $60 million per country where on average one million children are born every year, $12 would be available per child for immunization services. One of the advantages of investing in excess burden for poor people is that the investments become self-targeting, i.e. one does not need to consider specialized services for the poor, as they are notorious for becoming ‘poor’ services. While this does not exclude the possiblity of using vouchers and other mechanisms where payments are required for systems reasons, services for those conditions could be free or almost free in a poverty reduction programme. Moreover, if one focuses on outcomes, one does not necessarily have to target investments at specific disease categories. A very good example of this comes from Ghana ( Adjei 1999). Ghana has undertaken profound health sector reforms by adopting and implementing a sector-wide approach. The government agreed with international agencies and bilateral donors that resources would be pooled and and used towards an agreed strategic framework. During 1997, &, 1998, immunization coverage has increased by about 20% (from approximately 50%–70% for measles). What are the reasons? There appear to be several: Vaccine procurement was protected in a general procurement mechanism. There was a shift in resources from tertiary care to district care. District support increased from 22% in 1996 to 39% in 1998 in national health budgets. Private healthworkers including midwives have become involved in immunization activities. This has dramatically increased the number of sites at which immunizations take place. Outreach points have increased from 7 to 11 per health facility. Immunization coverage has become an outcome measure used in the negotiation between central government and districts regarding resource allocation. The impact of health reforms on immunization in other countries appears to be mixed, but hard data is difficult to come by. Decentralization appears to have had a negative effect in many countries because central functions such as procurement suffered. In Latin America at least these effects were temporary (Ciro de Quadros, personal communication). In Uganda the reform process apparently led to the cutting of all resources of outreach services, which had a dramatic effect on coverage ( Ngoma 1999). A detailed review of the impact of sector-wide reforms is in preparation by the WHO. It is important in this context to conclude that reforms do not necessarily have a negative impact. The issue is therefore not whether the investments go into one pot or not – this will depend on the stage of reform in each country. Strategies for investments in health in relation to poverty reduction may with appropriate know-how be used to promote reforms to achieve better services rather than inhibit them. We should be able to overcome vertical in favour of horizontal entrenchment. To reach out to poor populations represents a great challenge. This is where the biggest gains of poverty reduction are likely to be achieved, as illustrated by the striking differences in coverage between routine polio 3 immunization and national vaccination days ( Table 3). Similarly high coverage has been achieved with ivermectin distribution in Africa, where quantitative randomized trials showed that a community-driven approach resulted in better coverage than health centre-driven ones ( TDR 1996b). Thus it would appear that we now have several successful models: Polio national immunization days with community mobilization; Ivermectin distribution directed by communities; Health sector reforms shifting resources from tertiary to primary care; Contracting of privately practicing midwives and other health personnel; Securing resources for mobile services including transport. The optimal mix of these would of course depend on geography and other local factors. The costing of outreach services is a priority in this perspective. They may bring up the cost of services severalfold, depending on the circumstances. Over the last 1½ years, kick-started by a meeting in the World Bank, an analysis of immunization services has taken place. The analysis showed: stagnation of immunization services globally with a decline of EPI coverage for certain countries as well as marked regional discrepancies ( WHO 1999c); newly developed, efficacious vaccines against major killers are not being introduced into poorer countries, the gap between the number of vaccines used in the ‘North’vs. the ‘South’ is widening; limited investment into vaccine research for diseases that predominate in the poorest developing countries. As a result of this analysis the major partners in the field decided to strengthen their global effort in this field, leading to the formation of the Global Alliance for Vaccines and Immunization (GAVI) in July 1999 ( GAVI 1999a). GAVI has the following strategic objectives: Improve access to sustainable immunization services; Expand use of all existing, safe and cost-effective vaccines where they address a public health problem; Accelerate development and introduction of new vaccines and technologies; Accelerate R & D efforts for vaccines needed primarily in developing countries; Make immunization coverage a centrepiece of international development efforts. The main instruments created for GAVI to advance these objectives ( GAVI 1999a) are; A Global Fund for Children's Vaccines (GFCV) with the aims of purchasing vaccines and safe injection materials, financing access, infrastructure and R & D. The fund's first priority is to secure availability of newer vaccines (Hepatitis B, Haemophilus influenza b, yellow fever) ( Figure 2); A Governing Board comprising 11 members from partner constituencies. Dr Gro Harlem Brundtland, Director General of WHO, will chair for the first two years followed by Ms Carol Belamy, Executive Director of UNICEF, for the following two years; A small secretariat to implement the directions of the Board and ensure the involvement and representation of the broader immunization community; A Partners' Working Group to ensure Board decisions are translated into operational actions appropriate to each lead agency; Task forces of limited duration to address specific issues; A biannual meeting to bring together the broader immunization community. Structure of the Global Fund for Children's Vaccines. The intention of GAVI's modus operandi is to ensure that the partners do the work and that the secretariat remains small to avoid duplication of efforts. The working group with its weekly teleconferences appears to be an important mechanism for coordination with strongly dedicated people of the main partners. The Fund became reality before the end of the year 1999 with a contribution of $150 million per year for five years from the Bill and Melinda Gates Foundation. This needs to be matched by a 30% contribution from other sources to become a charity with tax-free status. The UNICEF national committee of the US has taken on that challenge. Initially the Fund will be used to supply HEP B, HIB and yellow fever vaccines to the poorest countries with a per capita GNP < $1000. China, Indonesia and India are considered special cases because of their purchasing power and vaccine production capacity. Thus GAVI will discuss with these countries how best to support them through mechanisms other than external purchase. Countries are invited to submit proposals which will be reviewed on the basis of clearly defined eligibility criteria ( Unicef 1999b), giving considerable scope for synergy with HIPC-based investments. With an estimated $1 billion potentially available over the next five years, Figure 3 illustrates the possible disbursement of funds to sets of countries in $50 million increments. These countries would receive fully funded vaccines for three years; support would then be tapered off by 25% per year with the last 25% continuing for three years, giving a total support period of eight years. $1 Billion distributed in 4 separate $250 million trunches each starting with $50 million for 3 years. Different shaded areas relate to different cohorts of countries with different implementation rates. The cost of vaccines and safe injection material for a fully immunized child is approximtely $10. Thus $200 million will cover 20 million children, i.e. about half of the total child cohort in eligible countries. Assuming that many countries would need to strengthen their immunization services first, both in terms of infrastructure and access to qualify, the programme is being phased in to reach maximum capacity in the third year. With the Fund, GAVI has extraordinary new opportunities in relation to immunization, but if they are to materialize fully, some problems need to be resolved. Many countries targeted for this programme have low coverage of DPT3, often < 60%. Their infrastructure was eroded in the 1990s and coverage capability is limited. A substantial proportion of children may not receive a full immunization schedule. However, the polio eradication initiative greatly strengthened infrastructure in recent years. As outlined above, clear successes have been achieved in sector and community-based research. Strengthening current services is a challenge to GAVI partners already involved in supporting health and immunization services, notably the countries themselves, UNICEF, WHO, bilateral agencies and the development banks. We do not consider it likely that the GFCV will play an instrumental role here initially. GAVI will support the strengthening of existing mechanisms. HEP B and HIB vaccines will be required for newborns every year in the poorest countries. Thus their continued financing must be secured. While the costs of the vaccines is likely to continue to fall, substantial investments will be required on a continuing basis, necessitating collaboration of all parties concerned. The governments of eligible countries have a particularly important role to play: Only if it is a priority to them can bilateral agencies provide assistance and development banks concessionary loans. New vaccines, such as one agains pneumococcal pneumonia, are in the pipeline. This vaccine alone could save more than a million children from dying of acute respiratory infection. Unless we can secure the funding of currently available vaccines, we cannot ensure funding of new ones. On the other hand, if we are successful with the former, we will have a good chance to raise the resources required to introduce new vaccines. This is illustrated in Figure 4. The need to secure sustainable financing to secure funding for new vaccines. Since the last biotechnological revolution, we have seen a continuos trend towards a sharper distinction between public and private sector, which has accelerated after the collapse of the communist system. Within R & D the roles have also become more distinct: The public sector plays a key role in supporting basic, clinical, epidemiological and operational research while the private sector tends to be responsible for product development. Product development is, in part due to rules and regulations imposed by the public sector, a complex operation spanning intellectual rights related to discovery, preclinical and clinical development, production, marketing and post marketing surveillance. The driving force for the private sector is profit. Through a century of competitive development, the R & D industry has become the most effective actor in this field, and continues to undergo change to retain that competitive edge especially in a globalized market. A problem arises for unprofitable products; so far, the public sector has had to take a responsibility for these. Most who have been involved in public sector product development realize that it is difficult to match the range of expertise and competence required. Thus, if the public sector could guarantee a market that would engage the private sector, many obstacles would be overcome. This is what is called the ‘pull’ mechanism. For some products, such as the pneumoccocal vaccine which has a market in the industrialized countries, the pull mechanism does not need to be very substantial. Potential availability of $100–200 million for the poorest countries is expected to be sufficient. On the other hand, vaccines that are of greater use to poor populations and countries, such as vaccines against malaria, HIV/AIDS or tuberculosis, would require a stronger pull, on the order of magnitude of a billion dollars or more per year for at least five years. We are awaiting private sector assessments. There is considerable interest in pursuing this mechanism by the World Bank, by Jeffrey Sachs and colleagues at Harvard, and the US government. If the GFCV were to become a vehicle for such a pull mechanism, it would need to be substantially strengthened. If increased investments in vaccine R & D can be achieved, many resent discoveries and tools provided by basic science would become part of a development effort. These include identification of protective antigens selectively synthesized in vivo where tissue damage occurs; functional and structural characterization of antigens derived from genomics efforts; rationalization of the immunization process itself through improved methods for introduction and expression of vaccine DNA and selective targeting to the presentation mechanisms of the immune system ( Hoffman & Liu 1999); and simpler The most important challenge for GAVI is to that all whether in the or in the field, will as part of this effort to and health, through the use of safe
Abengourou, with a population of 444,000 \n inhabitants, is one of the ten regions in Cote \n d'Ivoire. In this region, the fight against HIV/AIDS is \n enforced by a Regional Coordination Committee. What is \n special compared to other regional initiatives in the fight \n against HIV/AIDS is the organizational and community \n approach as well as the system established for financing activities.
OBJECTIVE: Previous economic analyses of tuberculosis control interventions have focused on the provider perspective. To assess the overall economic impact of the disease and the adequacy of current control strategies from a societal viewpoint, the determination of direct and indirect patient costs is required. SETTING AND DESIGN: In a cross-sectional survey, all adult tuberculosis patients who completed treatment between August 1996 and February 1997 at 16 randomly selected government health care facilities in Thailand (n = 673) were interviewed using a structured questionnaire. Information were obtained on direct and indirect patient costs before and after diagnosis, and on financing methods and changes in household consumption patterns. All results were stratified for three levels of patient household income: above national average, below national average but above the poverty line, and below the poverty line. RESULTS: Illness-related costs particularly affected patients with incomes below the poverty line (n = 153). In this group, average out-of-pocket expenditures for the disease amounted to more than 15% of annual household income, while incomes were reduced by 5 % due to illness-related effects. Expenditures were most frequently financed from household savings or transfer payments from community members and relatives. However, 11.8% of patient households took out bank loans, and 15.9% sold part of their property. CONCLUSION: The current low case detection and treatment completion rates for tuberculosis patients in Thailand may partly be due to the inability of poor patients to cope with the economic consequences of diagnosis and treatment. Suggested improvements include the strict enforcement of an existing government policy of free care, the further decentralization of services to reduce travel costs and work absences, and social security payments for patients undergoing treatment.
As of July 1994, there were 565,856 human immunodeficiency virus (HIV)-infected persons in South Africa, half of whom were 18-25 years of age, and 27% of the adult population is likely to be infected by the year 2010 if current risk behaviors persist. By 2005, the cost of acquired immunodeficiency syndrome (AIDS) to South Africa's health service could reach R18 billion. The newly established National AIDS Task Force seeks to prevent further HIV transmission by promoting condom use, improving control of sexually transmitted diseases, providing a safe blood supply, adopting universal precautions for skin piercing and surgical procedures, preventing intravenous drug use, providing information about prenatal transmission, promoting policies that raise women's status, and socioeconomic development. The personal and social impact of HIV infection will be ameliorated through comprehensive health care and counseling for AIDS victims and their families, protection of infected individuals from discriminatory practices, sustainable social services and benefits to meet the needs of those with AIDS, and promotion of policies that address the socioeconomic consequences of AIDS. On the administrative level, interventions are planned to promote intersectoral coordination, ensure adequate financing, promote community involvement, decentralize planning and management, ensure program monitoring and evaluation, forecast HIV trends, and share technical expertise.
The costs of the medical care needs of AIDS patients are well above the average per capita expenditure on health care in many sub-Saharan African countries. These costs may become completely unaffordable as specific anti-viral drugs come onto the market, and the burden will fall on health networks, whose present strained budgets show no real signs of increase. In addition, pilferage, mismanagement and inefficiency continue at the few existing hospitals. As the total number and percentage of hospitalized patients with AIDS increases, the hospital networks (and the health services as a whole) risk collapse. The risks are of the same magnitude for both rural and urban hospitals - the former will not be able to deliver the necessary minimum quality of clinical standards, the latter will be flooded by too many patients. Achieving reasonable standards of hospital management and decentralization of curative care are critical targets for at least avoiding the risk that donors may be unwilling to finance specific anti-HIV drugs for these poor (and high-prevalence) countries.
Italy now ranks 8th in the list of countries worst hit by AIDS. The relatively low figures for homosexual AIDS cases give no cause for complacency. It is not known yet if the message about 'safe sex' has got across to homosexuals, or if there has been underreporting and the numbers with AIDS will start soon to show the same rising curve as that for drug users. The Vatican, as was always expected, has said 'no' to the use of condoms to combat the spread of HIV, even though its use would not be to avoid conception but to prevent disease. Many doctors working in the field resent the lack of consultation and communication between Rome and the regions. But Italian health services are decentralized; the 21 regional health authorities are autonomous bodies. They have never looked to central government for specific directions, but they do desperately need extra funding. Their literature has been important as means of countering 'disinformation' from the press, often prone to sensationalism. Discrimination against children of parents infected with HIV has occured in schools and frequently seropositive employees have been fired. Local authorities are now making great efforts to impart the correct information. The Italian family planning association, UNICEMP, plays a supportive role in the education and information campaign. Many voluntary organizations provide counseling. The government national commission on AIDS set up a free telephone service where experts are available to answer questions from the public. But although 18,000 calls were made in the 1st 6 weeks of opening, hardly any inqueries at all came from those most at risk--the drug users.
To better understand and implement the extensive World Bank study on the financing of health, this limited article was enjoined to discuss salient features of the study and their potential for implementation. With technology for diagnosis and treatment driving health costs up, we are left with still affordable and all around more effective programs on protection and prevention that would be more cost- and health effective in a world where financial health resources are static or being cut back. Health programs and hospitals are generally inefficient with an underutilization of peripheral services. A redesign of integration systems is discussed. 4 policy reforms do, in effect, constitute a positive and feasible agenda. All of these policies will require great political commitment for their unpopularity. 1st, charging users of health services except those truly unable to pay is deemed more just. 2nd, provisions of insurance or other risk coverage (e.g. social security) need expansion. 3rd, effective use of nongovernment resources, the most vague policy reform, is discussed in terms of its implementation. 4th, decentralization of government health services is a prerequisite for achieving significant reform in financing the services. The main point of the World Bank study is active community participation which stops the paternalistic government-mendicant demanding populace pathology that is common today. A special study is suggested which would involve the World Bank and other internal organizations in analyzing the financial and technical support furnished to strengthen, endorse, and empower the reform policies.